Provider Demographics
NPI:1164419008
Name:BOTTESI, KENNETH J (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:BOTTESI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45634 SCHOENHERR RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-6024
Mailing Address - Country:US
Mailing Address - Phone:586-566-3000
Mailing Address - Fax:586-566-3070
Practice Address - Street 1:45634 SCHOENHERR RD
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-6024
Practice Address - Country:US
Practice Address - Phone:586-566-3000
Practice Address - Fax:586-566-3070
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010595642084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4910630Medicaid
MI4592447Medicaid
MI4910926Medicaid
MI4592447Medicaid
G32658Medicare UPIN